Knowledge, use (misuse) and perceptions of over-the-counter analgesics in sub-Saharan Africa: a scoping review

ABSTRACT Background Over-the-counter (OTC) analgesics are safe for pain-management when used as recommended. Misuse can increase the risk of hypertension and gastrointestinal problems. Objective To conduct a scoping review of the uses and misuses of OTC analgesics in sub-Saharan Africa, to inform strategies for correct use. Method Following guidelines for conducting a scoping review, we systematically searched Pubmed, ResearchGate and Google Scholar databases for published articles on OTC analgesic drug use in sub-Saharan Africa, without restrictions on publication year or language. Search terms were ‘analgesics’, ‘non-prescription drugs’, ‘use or dependence or patterns or misuse or abuse’ and ‘sub-Saharan Africa’. Articles focusing on prescription drugs were excluded. Results Of 1381 articles identified, 35 papers from 13 countries were eligible for inclusion. Most were quantitative cross-sectional studies, two were mixed-methods studies, and one used qualitative methods only. About half (n = 17) the studies recorded prevalence of OTC drug use above 70%, including non-analgesics. Headache and fever were the most common ailments for which OTC drugs were taken. Primary sources of OTC drugs were pharmacy and drug shops, and family, friends and relatives as well as leftover drugs from previous treatment. The main reasons for OTC drug use were challenges in health service access, perception of illness as minor, and knowledge gained from treating a previous illness. Information regarding self-medication came from family, friends and neighbours, pharmacies and reading leaflets either distributed in the community or at institutions of learning. OTC drug use tended to be more commonly reported among females, those with an education lower than secondary level, and participants aged ≥50 years. Conclusion Self-medicating with OTC drugs including analgesics is prevalent in sub-Saharan Africa. However, literature on reasons for this, and misuse, is limited. Research is needed to educate providers and the public on safe use of OTC drugs.


Background
Analgesics obtained over-the-counter (OTC) such as paracetamol, ibuprofen and aspirin are widely used to manage pain including fever, headache, musculoskeletal pain and menstrual cramps [1,2]. They are safe if taken as recommended, but misuse has been associated with conditions such as hypertension and gastrointestinal tract infections [3,4]. Many people use OTC drugs as their first line of treatment, without formal prescription, because they are affordable and accessible from small drug stores, street vendors and friends and family [5].
Obtaining medication without the authority or prescription of a physician enables people to access treatment quickly and reduces the burden on the health care system [6][7][8]. However, if not used as recommended, OTC drugs can result in wasted medical resources and harms related to side effects, drug toxicity, drug-drug interactions, and drugdisease contraindications [9][10][11][12]. More positively, OTC drug use is a component of self-care, reflecting the ability of individuals, families and communities to promote, maintain health, prevent disease and to cope with illness with or without the support of a health care provider [13]. Once equipped with the correct information, people can make decisions to manage their health [7,14,15].
Globally, research on OTC drug use has been conducted among specific groups such as students [8,16,17], pregnant women [18] and children [19,20], as well as the general population [9,21]. This research has covered use of range of OTC drugs in high income countries [2,22], but little research has been conducted about the knowledge, use (and misuse) and perceptions of OTC drugs including analgesics, particularly paracetamol and ibuprofen in low-income settings, including in sub-Saharan Africa. In a systematic review conducted in 2017, it was noted that OTC drug use including analgesics was prevalent in Ethiopia [7]. A study in South Africa showed that OTC analgesics were used for intravaginal insertion to increase sexual pleasure and other unintended purposes leading to substance abuse dependency [23], while a study on menstrual health in secondary school girls in Uganda, that some expressed concern about the effects of analgesics on fertility [24].
To map the prevalence and different forms of OTC analgesic use and misuse in sub-Saharan Africa and perceptions of such use, we undertook a scoping review. Scoping reviews use a structured process to map the coverage of a given topic in the literature and to identify knowledge gaps [25][26][27]. The findings of this scoping review will identify research gaps on OTC analgesic drug use, and inform future research on strategies to improve the use of OTC analgesics in the region.

Search strategy
Following scoping review guidelines [26], potentially eligible articles were identified through PubMed, Research gate and Google scholar. The search was conducted in January 2020, with terms as follows: 'Sierra Leone' OR Togo)))))).
There was no restriction on the study design, language or year of publication. Further articles were identified from reference lists of eligible papers.

Data abstraction
We included publications reported data on the use (or misuse) of OTC analgesics in sub-Saharan Africa. We excluded publications that focused on prescribed drugs, animal-based studies and studies conducted outside of sub-Saharan Africa. For each potentially eligible article identified, two authors (RK and RSC) abstracted the following information to identify eligible papers: study title, author, year of publication, country, study design, sample size, category of users, prevalence of self-medication with OTC analgesics and other drugs, common illnesses treated, common OTC drugs used and sources from which they were obtained, sources of information and the reasons for medication.

Results
A total of 1381 studies were identified from the database search. After removing duplicates, 48 studies were deemed potentially eligible, and their abstracts were reviewed using the inclusion and exclusion criteria above. Forty abstracts were found eligible for inclusion. Three were excluded because they involved prescription drugs and five did not specifically refer to analgesic use. Of these, 34 full-text papers were found. We were unable to obtain the papers for the remaining six articles through libraries or by trying to contact the authors. An additional four potentially eligible papers were identified from reference lists of eligible papers. Of these, one met the eligibility criteria, yielding a total of 35 papers included in the analysis ( Figure 1).

Characteristics of studies included
The 35 articles were published between 1989 and 2019, from 13 countries in sub-Saharan Africa. Study populations ranged in size from 57 to 9063 participants (total number of participants = 27,257). Thirteen studies were conducted in Nigeria, with others in Ethiopia (n = 9), Ghana (n = 2), Tanzania (n = 2) and one each from South Africa, Gambia, Mozambique, Eritrea, Zimbabwe, Democratic Republic of Congo, Cote d'Ivoire, Cameroon, and Kenya. Populations included secondary and university students (n = 6 studies), pregnant women (n = 6), among children and adolescents (n = 4), general populations (n = 13) and hospital-based studies including health care professionals (n = 2), and adult outpatients and caregivers (n = 4). Most studies used quantitative methods (n = 32), with two using mixed methods and one qualitative methods only (indepth interviews and focus group discussions) ( Table 1).

Prevalence, common ailments, drugs used and their sources
Of the 35 studies, 28 recorded prevalence of OTC drug use with both analgesic and non-analgesic drugs. In this paper we focus on the OTC analgesic use. Overall, 17 studies recorded a recall period ranging from one week to 12 months. The remaining studies did not indicate a recall period. Seventeen studies (60.7%) had a prevalence of OTC analgesic use above 70%. Specifically, prevalence among pregnant women was between 26-78%, students 55-82%, general community members 38-97% and hospital patients 45-89%. Twenty-one studies described common ailments treated with OTC analgesic drugs, namely headache (n = 15), fever (n = 13), cough and cold (n = 10), diarrhoea (n = 6) and general body/ joint pains (n = 5). These were similar by type of study population.
Paracetamol was the main OTC analgesic drug used, others were aspirin and ibuprofen. Paracetamol is generally considered to be a nontoxic drug without known side effects and a drug people can easily obtain. It was used to treat common illnesses such as headaches, fever, cough and gastrointestinal infections. Many of the papers included OTC drug use with other classes of drug, such as antibiotics, antimalarial and anthelminthic drugs.
The main sources of OTC drugs were pharmacies and drug shops in the community (n = 12), family, friends or other neighbours (n = 9), drug hawkers (n = 4), left over medication from previous treatments (n = 4) and patent medical stores (n = 3) ( Table 2).

Reasons, sources of information and socio-demographic characteristics for OTC drug use
In 19 studies, reasons for use of OTC drugs were explored. These related to challenges in the healthcare system such as long distances to the health facilities, long queues and limited health service staff. Drugs from pharmacies, hawkers or nearby shops without a prescription provided more ready access. In addition, the perception of illnesses as being minor and treatable with OTC drugs was mentioned in 13 of the studies. Other reasons were financial constraints (n=6) involving paying consultation bills but also the knowledge gained from previous treatments (n=5).
Thirteen studies recorded the main sources of information for OTC drug use and participants reported family members, friends and neighbours as the main source of information. Other sources were the pharmacies where they went to buy drugs, and drug information leaflets. The media, including the internet, were also an information source, including through advertisements. Table 3 shows socio-demographic characteristics associated with use of OTC drugs analysed in 16 studies. Five studies analysed the relationship between age and use of OTC drugs and majority showed that participants aged ≥40 years used OTC drugs more than the younger participants. However, one study found that younger participants used OTC drugs less than older participants (70% among those aged 14-40 years vs 50% for those aged ≥50 years)      [54]. Six studies reported that females use OTC drugs more often than males while one study conducted among children found out that boys used more drugs than girls [57]. There was also a correlation between education and OTC drug use, with six studies finding that respondents with low levels of education (mostly below secondary school level) tended to use OTC drugs more than those with higher levels of education [12,14,15,34,45,52]. In contrast, two studies found that those with lower level of education were less likely to use OTC drugs than those with higher levels of education [31,47] (Table 3).
Misuse of OTC drugs was explored in few studies. In two studies, participants reported that higher than recommended doses were taken [31,52]. A third study highlighted perceptions about drug misuse that can result in health hazards such as drug resistance [14].

Discussion
This is the first scoping review to assess the knowledge, use (misuse) and perceptions of OTC analgesics in sub-Saharan Africa. OTC analgesics use is widespread in sub-Saharan Africa to treat common ailments such as fever and headaches. OTC analgesics were obtained mostly from pharmacies and drug shops. Challenges with the formal health care system were cited as the main reason for using OTC drugs, along with perceptions of ailments as minor and not requiring treatment in a formal system.
The 35 studies included in this review provided evidence of a high prevalence of OTC drug use including analgesics in comparison to studies conducted in general populations outside Africa [58][59][60] which suggest a lower prevalence of self-medication of less than 20%, except among university students [3,4,17,61]. However, comparison is difficult because of differences in the demographic profile of study populations, recall periods, methodologies used and a lack of uniformity in defining 'self-medication' may have contributed to observed prevalence rates, a factor which Cooper [22] identifies as a challenge in a review of the global use (misuse) of OTC drugs (including analgesics). In addition, it is important to recognise that lax regulatory practices governing drug shops and pharmacies, as well as access to affordable health services, also influence OTC drug use and misuse [62,63].
In our review, OTC drugs including analgesics were used by all populations, including children and adolescents, students and pregnant women as has been noted in studies elsewhere [5,8,19,60]. The main reasons for use were to treat febrile illnesses at home and to avoid seeking medical attention unless symptom persisted. OTC drugs including analgesics were easily accessible from several sources including close friends and relatives. This easy accessibility, together with challenges in the formal health care services such as the long distances and absence of dedicated personnel explained the high prevalence of OTC drug use in the region [64,65].
Perceptions of risks involved in the misuse of OTC drugs was explored in three studies [14,31,52]. These found that people mainly misused drugs by taking more than the recommended dosage. Misuse of OTC drugs is understudied in sub-Saharan Africa despite risks that may be associated with harms including addiction, drug resistance and masking underlying symptoms of an illness [2,11,66]. A global systematic review [22], which included only two studies from Africa [49,67], noted that OTC drugs were misused. More studies need to be   conducted to understand the misuse of OTC analgesics to ensure that they are used responsibly, as advocated for by the World Health Organisation [13]. Quantitative cross-sectional surveys were the most common study design used to investigate OTC drug use; however, qualitative methods could offer indepth insights into misuse of OTC drugs. Further, there were few studies from East or Southern Africa. Evidence from these regions could help understand patterns of use and misuse of OTC analgesics across the sub-Saharan African region to inform policies to promote responsible self-care.
The differential use of OTC drugs by sociodemographic characteristics is useful for formulation of interventions and policies. For instance, females tended to report self-medication more than males and this is partly attributed to pains related with dysmenorrhea [33,66,68], but this may also reflect reporting bias, with males less likely to disclose analgesic use [69]. People with lower levels of education also tended to use OTC drugs, including analgesics, more than those with higher levels of education [12,14,15,34,45,52]. However, there were some exceptions, including prevalent OTC use by university medical students, as seen elsewhere [3,16,35,44]. The ease of access to drugs was given as the main reason why health workers, including medical students, took drugs without prescriptions raising concerns over misuse [11]. Therefore, regardless of education level, health education may need to be emphasised to support people to learn appropriate use of OTC drugs while eliminating their misuse.
A limitation of our review was that studies reported prevalence of both OTC analgesic drugs and non-analgesics combined, making it difficult to elicit analgesic use specifically.

Conclusion
OTC drugs, including analgesics, are commonly used in sub-Saharan Africa by men and women (including pregnant women), children and people from different geographical locations (both rural and urban) to manage febrile illnesses which some people perceived to be minor and treatable. However, while they can be easily accessed, their use and perceptions are not well-understood, especially in terms of misuse because this was understudied. Therefore, limited knowledge regarding misuse of OTC drugs was noted in this scoping review. Further research is needed to understand the specific use and misuse of analgesics in sub-Saharan Africa to inform better practice, and the reasons for increased reporting by females and those with less education. We recommend that studies (including studies using qualitative methods) focusing on OTC analgesics use specifically (rather than OTC drug use generally) be conducted to understand reasons for high prevalence and whether such use is appropriate. These can inform development of national guidelines, essential medicine lists, educational programmes and other effective mechanisms to promote rational medicine use by consumers.

Author contributions
RK and RSC undertook the review of all papers. HAW, SCF and JS provided advice and support during the review and analysis process. HAW, SCF and JS reviewed all drafts of the paper produced by RK and RSC. All authors approved the final version of the paper.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding information
This study was funded by the Institutional Strategic Support Fund (ISSF3), a Wellcome Trust Initiative, at the London School of Hygiene and Tropical Medicine.

Paper context
There is limited research on the use and misuse of OTC analgesics in low-income settings. We conducted the first scoping review on OTC analgesic use in sub-Saharan Africa, and found high prevalence of self-medication. This is likely to be due to ease of access and challenges accessing formal health care. Further research, including studies using qualitative methods, are needed to help understand patterns of use and misuse of OTC analgesics in the region, to inform policies to promote responsible use.